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As a Medicare beneficiary, where you live impacts the care that you receive and how you pay for that care. This page explains the District of Columbia’s regulations and policies and identifies some resources that may help you pay for Medicare coverage.
Financial help for Medicare beneficiaries who struggle to afford the cost of Medicare coverage is available through a Medicare Savings Program (MSP). In Washington, D.C., this program pays for Medicare Part B premiums, Medicare Part A and B cost-sharing; it may also pay for Part A premiums.
In most states, applicants seeking help with Medicare premiums receive one of three MSPs depending on their income: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Individuals (QI). But D.C. has replaced SLMB and QI with an expanded QMB program that cover applicants with incomes up to three times the poverty level. This is the highest income limit for MSP benefits in the U.S.
Enrollees can use QMB as a form of Medicare supplemental coverage, because Medicaid covers QMB enrollees’ Part A and B cost sharing as long as they see providers enrolled in both Medicare and Medicaid. Even if a provider isn’t enrolled in Medicaid, federal law prevents the “balance billing” of QMB enrollees for more than a small copay.
Income eligibility: The income limit for QMB is $3,189.99 a month if single and $4,310.01 if married.
MSP asset limits: There is no asset limit for QMB in Washington, D.C.
Medicaid for the aged, blind, and disabled (Medicaid ABD) can help pay for Medicare cost sharing, and cover some services not covered by Original Medicare – like vision and dental care. Medicare beneficiaries who meet Medicaid income limits can receive coverage for those additional services if they’re enrolled in Medicaid ABD.
Because QMB also covers Medicare cost sharing – and is available to enrollees with incomes up to three times the poverty level and has no asset limit – Medicaid ABD enrollees in D.C. primarily benefit from Medicaid’s coverage for services that Medicare does not cover.
In D.C., the Medicaid program includes a comprehensive dental benefit, which covers fillings, restorative care, and preventive visits. Medicaid also covers eyeglasses for enrollees who require at least one diopter of vision correction.
In Washington, D.C., Medicaid ABD includes QMB benefits and is called QMB Plus.
Income eligibility: The income limit is $1,063.33 a month if single and $1,436.67 if married.
Asset limits: The asset limit is $4,000 if single and $6,000 if married.
Medicare beneficiaries who are enrolled in Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help – a federal program that lowers prescription drug costs under Medicare Part D. Enrollees who don’t automatically receive this benefit can apply for it through the Social Security Administration (SSA). The income limit is $1,615 a month for individuals and $2,175 a month for spouses, and asset limits are $14,610 for singles and $29,160 for spouses.
If an individual has an income greater than the eligibility limit for Medicaid ABD but assets below the resource limit, they can become eligible for Medicaid through the Medicaid spend-down. This program allows enrollees to subtract incurred medical expenses from their income that is counted toward the Medicaid income limit.
In Washington, D.C., the Medicaid spend-down covers Medicaid ABD benefits and Long Term Services and Supports (LTSS), which means applicants with incomes above the eligibility limit for nursing home benefits or HCBS can use it to access those services.
The Medicaid spend-down has a coverage period lasting one month for community benefits (i.e., enrollees who don’t need long-term care), and six months for long-term care. Enrollees must submit proof of additional medical or long-term care expenses for coverage to continue beyond this period.
Income limit: The income limit is $682.42 a month if single or $718.33 a month if married.
A note about the Medicaid spend-down and long-term care: In D.C., applicants can qualify for Home and Community Based Services (HCBS) with incomes up to $2,349 a month (if single), and can then keep a personal needs allowance equal to that limit used to pay for health and living expenses.
However, if an applicant has even a dollar more in income, they are required to enroll in the Medicaid spend-down for long-term care coverage, and must submit medical expenses that are based on a more restrictive spend-down income limit (which is $682.42 a month for single applicants).
This distinction doesn’t affect nursing home enrollees, who have to pay almost all their income toward their care.
Asset limits: The asset limit is $4,000 if single and $6,000 if married.
This website has more information on the Medicaid spend-down in D.C.
As the U.S. population ages, a growing percentage of people reach a point when they need long-term care. In fact, 20 percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015. Medicare, for the most part, does not cover long-term services and supports (LTSS). Medicaid fills these gaps in Medicare’s coverage for long-term care, but its complex eligibility rules can make qualifying for benefits difficult.
Most seniors used to receive long-term care in nursing homes. Today, more enrollees receive these services in their homes. But some enrollees have medical or living situations that make nursing home care a better choice.
Income limits: The income limit is $2,349 a month if single and $4,698 a month if married and both spouses are applying. If only one spouse needs Medicaid, the single applicant income limit applies – and usually only the applying spouse’s income is counted.
Even though the income limit is $2,349 a month (if single), nursing home enrollees are not allowed to keep most of their income up to this limit. Instead, they have to pay all but a small portion of it toward their care, but can keep money to pay for health insurance premiums (such as Medicare Part B and Medigap) as well as a personal needs allowance of $70 each month.
Assets limits: The asset limit is $4,000 if single and $6,000 if married (and both spouses are applying). If only one spouse needs Medicaid, the other spouse can keep up to $128,640. Note that the asset limit excludes items such as most household effects, family heirlooms, some prepaid burial arrangements, and one car.
A first home will not disqualify an applicant from receiving nursing home benefits if they have less than $893,000 in home equity.
Medicaid programs offer varying levels of community-based long-term care benefits through Medicaid. Programs offering this care are called Home and Community-Based Services (HCBS) waivers, and cover long-term care services received at home, which may be less expensive than nursing home care.
Income limits: The income limit is $2,349 a month if single. This limit is used when only one spouse in applying for HCBS – and usually only the applying spouse’s income is counted. The limit is $4,698 a month if married and both spouses are applying.
In Washington, D.C., recipients of HCBS can keep a personal needs allowance equal to the income limit of $2,349 a month per applicant (in 2020).
Asset limits: The asset limit for HCBS is $4,000 if single/$6,000 if married and both spouses are applying. If only one spouse needs Medicaid, the other spouse can keep up to $128,640.
A first home will not disqualify an applicant from receiving HCBS if they have less than $893,000 in home equity.
Spousal impoverishment rules allow a couple to separate their joint assets and income for the purpose of meeting eligibility requirements when one spouse needs LTSS. The spouse not applying for long-term care services is sometimes called the “community spouse.”
Spousal impoverishment rules allow the community spouse of a Medicaid LTSS beneficiary to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income. Nursing home enrollees would pay all of this income toward their care if they couldn’t transfer it to a spouse.
In D.C. in 2020, these community spouses are allowed to keep:
Note that eligibility rules for Medicaid LTSS programs are different than those for other Medicaid benefits. Normally with Medicaid benefits, the state looks at income of both spouses regardless of who applies. For LTSS, only the applying spouse’s income is counted.
Federal law mandates that states restrict eligibility for Medicaid nursing home and HCBS to applicants with a home equity interest below a certain dollar amount. In 2020, states set their home equity limits based on a federal minimum home equity interest of $595,000 and a maximum of $893,000.
Washington, D.C. stipulates that applicants can have no more than $893,000 in home equity to qualify for Medicaid LTSS benefits.
Because long-term care is expensive, individuals may give away or transfer assets to others so they can become eligible for Medicaid nursing home care or HCBS. As a discouragement, federal law requires states to have a penalty period for Medicaid nursing home applicants who have transferred assets, and states can also apply a penalty for HCBS. Medicaid will not cover LTSS during this penalty period. However, enrollees who have a penalty can sometimes still receive receive regular Medicaid ABD benefits.
Washington, D.C. chooses to have an asset transfer penalty for both nursing home care and HCBS. The penalty is based on a five-year look-back period when asset transfers and gifts are prohibited. This period is calculated by dividing the value of gifts and asset transfers by the average monthly cost of nursing home care (which is about $12,883 in D.C. in 2020).
Medicaid agencies are required to attempt to recover their payments for long-term care and related medical expenses for enrollees who were 55 or older. States can also recover the cost of all other Medicaid benefits. This is called estate recovery.
As of 2015, Washington, D.C. had chosen to recover the cost of all Medicaid benefits received beginning at the age of 55. This means D.C. pursues estate recovery from Medicaid expansion enrollees.
However, D.C. will not pursue estate recovery as long as there is a surviving spouse, or a child who is under 21, blind or disabled (and still living in the Medicaid enrollee’s home).
Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but Medicaid may attempt to recover the cost of MSP benefits received through that date.
This website has more information about estate recovery in Washington, D.C.
Free volunteer Medicare counseling is available by contacting the D.C. Health Insurance Counseling Project (HICP) at 202-727-8370. This is D.C.’s State Health Insurance Assistance Program (SHIP). HICP can with Medicare enrollment, evaluation of Medicare Advantage and Medicare Part D plans, and understanding Medigap options. They may also be able to offer referrals to local agencies for services like home care and long-term care.
Elder law attorneys are a helpful resource in planning for long-term care coverage. Use the search feature from the National Academy of Elder Law Attorneys (NAELA) to find an elder attorney locally.
D.C.’s Long Term Care Ombudsman Program can help Medicare beneficiaries understand their long-term care options. This program advocates for the rights of residents of long-term care facilities and HCBS recipients, and investigates complaints related to LTSS received in D.C.
Medicaid is administered by the Department of Health Care Finance (DHCF) in D.C. You can’t currently apply for Medicaid ABD or an MSP online. But this website contains a printable Medicaid application you can submit at an Economic Security Administration (ESA) service center.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare technical assistance contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He has also been in the consulting world, including at Sachs Policy Group, where he managed projects for Medicare and Medicaid clients.